Category: APHA IH Section

World Rabies Day: Rabies Prevention Around the World

by publichealthtalks, posted in APHA IH Section, Infectious Disease, Policy and Advocacy

September 28th is World Rabies Day! This day of observance was created by the Global Alliance for Rabies Control (GARC) to spread awareness about the disease and educate others on how to prevent it. This year’s theme is Rabies “Share the message. Save a life.” 

Rabies is a preventable viral disease that affects only mammals and is transmitted through the saliva, cerebral spinal fluid or brain tissue of an infected host. If untreated, rabies is fatal. Most commonly, the disease is transmitted through a bite, but can also be transmitted if the infectious material gets directly into the eyes, nose, mouth or an open wound.  Rabies infects the central nervous system and causes a “disease of the brain.” Early symptoms of rabies can include fever, headache and fatigue – symptoms that are similar to many other illnesses such as the flu or common cold. However, as the disease develops, symptoms specific to rabies begin to appear: insomnia, paralysis, hallucinations, agitation, hypersalivation, difficulty swallowing and hydrophobia. The disease typically results in death within a few days after the onset of these rabies-specific symptoms.  

In the United States, reported rabies cases have shifted from mainly domestic animals to predominantly wildlife animal reports. Specifically, more than 90% of all rabies cases today are from wild animals. In addition, the number of rabies-related deaths in humans has decreased dramatically from 100 cases per year in the 1900’s to 1-2 per year. Our efforts to encourage prophylaxis after an exposure and the effectiveness of the vaccine have proven successful in decreasing rates of rabies in the United States.

However, rabies is found on every continent other than Antarctica and some continents struggle with the burden of rabies more than others. The overall death rate for rabies around the world is estimated at a staggering 59,000 people a year. Countries in Africa and Asia are affected by rabies disproportionately than the other continents and almost half of the victims of rabies in these countries are children younger than 15 years.

A main reason that such a young population affected is due to uncontrolled canine rabies in these countries. Canine rabies – which spreads from dog to dog – is actually the cause of 98% of human deaths globally. In the United States it has been eliminated because many people keep their animals vaccinated to prevent this type of rabies from re-entering our environment.  However, in many other countries, stray dogs roam around neighborhoods freely and when they contract rabies, they likely spread it to many people (primarily children) they come in contact with. Scientists predict that if 70% of dogs are vaccinated for rabies in an area, rabies can be controlled and human deaths will decrease.

Haiti has the highest number of human deaths by rabies – around 2 deaths per week. CDC and the Government of Haiti have started an animal rabies surveillance program (2013) to detect and have situational awareness of which regions of the country are greatly affected by rabies. In 2015, CDC also evaluated how many dogs were vaccinated in the country and found that only 45% of dogs received their shots. In addition, the total amount of dogs in the country was actually double the number they initially predicted. After these studies were done, the CDC helped train animal health workers to conduct large dog vaccination campaigns and continue rabies prevention efforts.  Many children started bringing their puppies to the events and were proud of their certificates ensuring their dogs had been vaccinated. It is CDC’s (along with the Government of Haiti) hope to reach a 70% vaccination rate among their dog population and sustain it for five years – long enough to create a ripple of effect among human deaths due to rabies.

CDC has helped establish similar campaigns in other countries. For example, they have trained animal control officers in Ethiopia to capture, vaccinate and release stray dogs as well as monitor human exposure cases and keep track of post-exposure prophylaxis (PEP) treatments.  In Vietnam, while there is not a high human death rate for rabies – 91 per year, the government spends an extraordinary amount of money on expensive PEP. It is much more feasible to vaccinate dogs than provide the costly post exposure treatment – $1.32 dollars vs one course of PEP at $153 dollars.  The CDC has helped support Vietnam in improving their rabies surveillance and coming up with new approaches to vaccinate their dogs and achieve the 70% canine vaccination goal.

The World Health Organization has been having meetings to discuss ways to eliminate rabies in Africa too. This past month, representatives from 24 countries in Africa met in Johannesburg to share information from a study they conducted regarding rabies.  The representatives pitched ideas for implementing the new recommendations for human rabies vaccines and how to improve surveillance dog vaccination campaigns. These meetings are exciting as they provide new insight for the global plan to achieve zero deaths from rabies.

Single countries like the Philippines, have proved to be great examples for national campaigns organized against rabies. The Philippines holds a nationwide World Rabies Day celebration as part of its educational outreach campaigns each year. The celebration has continued to grow yearly as more and more events are added to the agenda. It’s success emphasizes the importance of a program that is led and supported by their own national government and how the topic of rabies elimination is valued by the country’s leaders.

Overall, targeting the countries where rabies poses a significant risk and coming up with goals, campaigns and new tactics to eliminate rabies are substantial goals for the globe and many lives will be impacted by the CDC, the WHO and its many public health partners. But what can YOU do on a personal level that can also impact many lives? Here’s a quick checklist to follow:

  1. To start, you should always take your pet to the vet to get vaccinated for rabies regularly.
  2. Spaying or neutering your pet can also help with decreasing the amount of stray and potentially dangerous animals into your pet’s environment.  
  3. Always supervise your pet when they are outdoors. Wild high risk animals for rabies such as raccoons, coyotes or opossums can be in your backyard.
  4. Lastly, avoid contact with wild or unfamiliar animals (including dead animals). As tempting as it is to pet a stray cute kitten or dog, it is in your best interest to not feed or handle them.
  5. Continue sharing the message and saving lives!  Happy World Rabies Day!

Antibiotic Resistance: Hidden Rates in Rural Areas of the Developing World

by pragmaticsolidarity, posted in APHA IH Section, Health Equity, Infectious Disease, Pharmaceuticals

When the age of antibiotics commenced in the 1950s, diseases and infections that typically would lead to humans being stigmatized by society, a permanent stay at a sanatorium, and then ultimately death were suddenly able to be treated quickly and efficiently. Penicillin and Streptomycin, not only improved a patient’s quality of life and longevity, but reshaped the very nature of treating infectious diseases. Health care professionals now possessed a cure to end the spread of the ailment and to eliminate the actual microorganism that created the suffering. However, these agents brought with them negative consequences that the global health community is still combating today – antibiotic resistance being one of the most significant issues. Antibiotic resistance is the predator’s (bacteria, virus, other microorganism) ability to resist an antibiotic that once was able to eliminate it. Although antibiotic resistance can occur naturally due to the cleverness of bacteria, fungi, and protozoa, the misuse of antibiotics in humans has tremendously accelerated the rate and severity of resistance. This inappropriate use of medicine and skills has led to difficult to treat infections like Extended-spectrum beta-lactamase (ESBL) producing strains of Enterobacteriaceae and even untreatable infections with no known drug on the market able to help an infected patient. The concept of antibiotic resistance often differs within the medical community when comparing the developed world, particularly urban areas, and the developing world, particularly rural areas. The amount of research, minds, and technology mobilized to address this unruly behavior by microorganisms varies drastically between the two sets.

In the urban developed world where physicians are equipped with the most innovative antibiotics known to man like daptomycin or the “Crispr” agents, antibiotic resistance is frequently a topic of discussion along with funding, human resources, and technology available to address it. Also, common ideology is that antibiotic resistance arises from the direct misuse of antibiotics rather than of natural causes. Contrasting the rural developing world, the aforementioned necessities to deter antibiotic resistance are often lacking due to health inequalities that unfortunately are ubiquitous throughout this fragile planet. More interesting though, health care professionals have formed an impression that antibiotic resistance more commonly stems from the dissemination of resistant organisms. With this mindset ingrained in world health leaders, the agenda has been to focus on prevention through this venue in the rural developing world – often lacking a call of funding to determine actual causes of antibiotic resistance and their associated rates in the rural developing world. While the dissemination of strains of Escherichia coli through feces and Multi-drug resistance Tuberculosis through poor air quality certainly needs to be addressed, the Centers for Disease Control and Prevention (CDC) released a report in 1999 encouraging health care professions to consider a range of socioeconomic and behavioral factors including misuse of antibiotics by physicians, unskilled practitioners, the public, counterfeit medications, inadequate surveillance, and political factors. To follow up with this theoretical account, the World Health Organization (WHO) conducted a survey across twelve (12) low to middle income countries across the world in 2015 to interview the population about their beliefs towards antibiotics and resistance. Some of the results are presented below:

  • In lower income countries, it was reported that antibiotic use is higher (42%) than in higher income countries (29%).
  • Across the countries, the range of patients obtaining their antibiotics with a physician’s prescription ranges from 56% to 93%.
  • The percentage of individuals believing they can use the same antibiotic as a family member did to treat a similar illness is 25% while 43% believe it is acceptable to buy the same antibiotic from a local pharmacy.
  • When patient’s start to feel better, 32% of the those interviewed believe they can stop the antibiotics and not follow through with full course.
  • When treating colds and viruses, 62% of respondents believe antibiotics could be used to treat these ailments.
  • Finally, 44% of those interviewed believe antibiotic resistance is only a problem for those regularly taking antibiotics.

These specific social results from patients in the developing world directly conflict with the thought of the major distributor of antibiotic resistance being through dissemination of the disease. The beliefs presented through these percentages seem to lead to a whole host of factors being involved similar to the developed world. In addition to these social results, PLOS Biology released data in 2018 that Escherichia coli was resistant to commonly prescribed antibiotics like ampicillin (92%), ceftazidime (90%), cefoxitin (88%), streptomycin (40%) and tetracycline (36%) in the rural areas of Sikkim, India in pre-school and school-going children. The Journal of the Pediatric Infectious Diseases Society reported similar rates among children in 2015 with Klebsiella pneumoniae having a median resistance to ampicillin with a rate of 94% in Asia and 100% in Africa, and cephalosporins having a rate of 84% in Asia and 50% in Africa. Also, The World Health Organization informed the global community that in Malawi in 2018, nearly 100% of Neisseria gonorrheae genital isolates were non-susceptible to ceftriaxone and roughly 15% were non-susceptible to azithromycin. When analyzing both the social and technical results from above, a renewed emphasis and novel perspective needs to be created in order to properly address antibiotic resistance in the rural developing world.

At the beginning of this year (January 2018), the World Health Organization released its initial reports utilizing an innovative reporting system for antibiotic resistance christened Global Antimicrobial Surveillance System (GLASS). This system was developed in order to preserve human and animal health throughout the globe in relation to antibiotics and their resistance. Although GLASS was officially launched in 2015, it is still in its early implementation period with only 22 countries reporting on actual resistance within their nation states and 40 countries reporting on their national surveillance program. However, GLASS aims at a variety of measures that will ensure antibiotic resistance is more appropriately addressed in the rural developing world by providing a standardized approach to collection, analysis, and dissemination of information to participating countries. GLASS will strengthen nation states antibiotic resistance surveillance systems and modify the data being studied from solely laboratory data to epidemiological, clinical, and population-level data. The preliminary results that were released by WHO revealed that across the 22 reporting countries, there were 500,000 individuals suffering from an infectious disease with antibiotic resistance. Although this data varies with completeness and accuracy across countries, the outcomes highlight the global emergency antibiotic resistance posses from the urban developed world to the rural developing world and everywhere in between – these mutated organisms will fail to respect national borders.

The global health bodies throughout the world have initiated programs and offered advice to nations that will serve the battle against antibiotic resistance well. However, the concealed rates of resistance in the rural developing world will need to be undertaken medically and socially in order to properly end this global emergency. Pipeline innovative antibiotics like relebactam, a novel beta-lactamase inhibitor and an educational emphasis on behavior habits will aid these parts of the world – but the health community will fall short unless the world changes its perception of antibiotic resistance in the countryside of Cambodia, the rice terraces of Vietnam, the jungles of Belize, and areas with similar socioeconomic status.

An “epidemic of poor quality”: New study finds that poor healthcare quality leads to millions of deaths globally

by Yara Asi, posted in APHA IH Section, Health Systems, MDGs / SDGs, Policy and Advocacy, Research

This is part 1 of a 4-part series on global healthcare quality.

The Sustainable Development Goals (SDGs), the global effort led by the United Nations to prioritize and standardize development goals in every country for the period 2015-2030, offer ambitious targets when it comes to the world’s health. SDG 3 is focused entirely on outcomes of health and well-being, such as reducing maternal mortality, ending diseases like AIDS and malaria, achieving universal health coverage (UHC), and ensuring universal access to reproductive health care. Other SDGs, such as Goal 2 which calls for zero hunger and Goal 6 that aims for universal and equitable access to safe drinking water as well as equal and adequate access to sanitation, have obvious implications for health. However, a recent Lancet Global Health Commission, chaired by Associate Professor of Global Health Dr. Margaret Kruk of the Harvard T.H. Chan School of Public Health, has come to some surprising conclusions about health systems in low- and middle-income countries (LMICs). Despite a push in humanitarian advocacy and research to focus on increasing healthcare access in LMIC, it is the quality of healthcare that is received by patients in these environments that may require more of our attention. The Commission estimates that as many as 5 million die each year because they are receiving poor-quality healthcare- more than a million more people than those who die due to no access to care at all (3.6 million). That means that annually, 8.6 million people living in LMIC are dying due to poor-quality healthcare systems. Poor quality care can be dangerous for patients, provides misleading data points about healthcare system improvements, and may support corrupt and fraudulent behavior by parties with power in the health sector. Is it possible to achieve the SDGs in this environment?

Health systems should be judged on “what they do for people- not how many doctors they train.”

Dr. Kruk describes quality healthcare systems as based on three factors: effective care, trust of the people, and a system that is able to adapt, both in cases of acute emergencies and with a longer-term vision. While many advancements in access can be supported by metrics, it is possible that we haven’t been measuring some of the factors that really matter. Dr. Kruk told NPR that health systems should be judged on “what they do for people- not how many doctors they train.” The Commission’s study, which was published by the Lancet earlier this month, found that the millions of deaths each year that can be attributed to poor health systems included many deaths due to factors the SDGs explicitly seek to reduce, such as neonatal conditions and traffic accidents. While one of the central tenets of SDG 3 is UHC, the Commission argues that the quality of care “is not yet sufficiently recognized in the global discourse on UHC” and that countries undertaking policies that bring them to UHC “must put better quality on par with expanded coverage” to improve health. The Commission identifies several individual initiatives in LMIC that are developing mechanisms for quality measurement and improvement. However, it is clear that improving the quality of care has not received the effort that expanding access to care has achieved, which will undoubtedly undermine efforts to achieve the SDGs, even if UHC is attained. While expanding access to care must remain a global priority, we cannot discount the need to ensure that care given is of high quality as well. Several studies from LMIC during the period of the Millennium Development Goals (2000-2015) suggested that in some instances, expanding access to care did not lead to more positive health outcomes because the quality of the care received was poor. However, we still do not even have highly rigorous and consistent tools with which to measure healthcare quality across global contexts in a way that would allow for standardized measures and generalizable conclusions.

Aside from the historical focus on access to care by humanitarian and governmental actors, there a few other reasons that quality of care has not received the appropriate amount of attention of donors and policymakers. Healthcare systems in LMIC are generally disintegrated, with pockets of government services, humanitarian agencies, and private facilities operating throughout the country. This complexity allows for the intrusion of many political and logistical barriers to providing high quality care consistently. In the public sector, corrupt bureaucrats may opt to control who is able to receive jobs at healthcare facilities rather than allow for a merit-based system where poorly qualified staff could be replaced by qualified employees, regardless of political factors. For-profit providers who have disparate financial interests may not properly follow treatment or diagnosis guidelines that are critical to quality care. However, entirely closing low quality facilities would leave some citizens with no access to care at all.

Dr. Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization, published a response to the Lancet Commission, agreeing that “nothing less than a revolution” is needed to ensure that high quality care is delivered in every health system around the world, an essential component of SDG 3. He posits that poor data is one of the largest barriers to improving healthcare quality, arguing that we must “go beyond counting simply what services are delivered to measuring how they are delivered.” He calls for a “global learning laboratory for quality,” where local lessons based on the “messy realities of health services” are prioritized, but where these lessons are then disseminated and can be implemented, measured, and compared in contexts around the world. Policymakers and practitioners working in LMIC must consider these factors when designing and implementing health services or research studies. The Lancet Commission points to five distinct foundations where learning and improvement in the process of care leads to higher quality: the needs of the population, governance in the health and non-health sectors, platforms of care, the healthcare workforce, and the tools needed to provide quality care. To avoid the rising “epidemic of poor quality” that the Commission found and to put LMIC on a successful path to achieving the SDGs, we can no longer ignore the pressing need to address healthcare quality just as much as access.

Global News Round Up

by ihsection, posted in APHA IH Section, News

Politics & Policies

According to a recent NPR-ProPublica investigation, we’re the only developed nation in the world where the rate of women dying of pregnancy-related complications is still rising, with more women dying from these causes here at home than in any comparably developed country.

The federal law protecting women from violence was set to expire at the end of the month, yet neither the House nor the Senate made renewing it a priority.

A pathbreaker in global health and a former CDC director, Bill Foege has some startling advice for young people interested in global health: Don’t have a life plan.  “Life plans are an illusion” he writes in his new book, “The Fears of the Rich, The Needs of the Poor.” Rather, he urges them to have a life philosophy that will guide them in the career and life decisions they make.

The United States’ commitment to global development does not look good compared with that of other wealthy countries – and it’s likely to get worse.

India has experienced a dramatic transition from a huge burden of infectious diseases to noncommunicable diseases, which now cause more than 69 percent of deaths in the country— almost 6 million each year.

Officials in Berkeley, Calif., have voted to require vegan-only food be served at city events and meetings that take place on Mondays.

Programs, Grants & Awards

The third UN High-Level Meeting on Non-Communicable Diseases (NCDs) on Sept 27, 2018, will review national and global progress towards the prevention and control of NCDs, and provide an opportunity to renew, reinforce, and enhance commitments to reduce their burden. NCD countdown 2030 is an independent collaboration to inform policies that aim to reduce the worldwide burden of NCDs, and to ensure accountability towards this aim.

The second phase of the “Science Management” course, aimed at researchers and managers from Portuguese-speaking countries in Sub-Saharan Africa and organised by the Calouste Gulbenkian and the “la Caixa” Foundations in collaboration with ISGlobal and the Manhiça Health Research Center (CISM), took place at the CaixaForum in Barcelona from September 10-14.

In the early 2000’s, three of Catherine Nalungwe’s children died one after another before the age of three. The cause of the children’s death became a source of pain and confusion for the family. Catherine later tested positive for HIV in 2002, but she had no access to treatment through nearby health facilities at that time.  With improvements in access to HIV/AIDS services in Zambia, she started treatment in 2004.

The opening session of the 2nd World Sepsis Congress, ‘Sepsis – still a Global Health Threat’ is now available on demand on YouTube and as a Podcast on Apple Podcasts.

A new global health institute aimed at tackling emerging health challenges was launched on Friday (Sep 21) at the SingHealth Duke-NUS Scientific Congress 2018.

Research

A new analysis has found that many of the products critically needed to fight some of the world’s most prevalent infectious are not likely to be developed based on current candidates in the research & development (R&D) pipeline, and reveals significant gaps in funding for health innovation.

Diseases & Disasters

A week after the storm made landfall at Wrightsville Beach, Florence continues to menace Southeastern North Carolina — both on and offshore.  After pummeling the region with wind and rain, the remnants of the storm haven’t dissipated and now have a slim chance to reform for a second go at the N.C. coast.

Water appears to have receded in some areas of the Carolinas, but more flooding from Hurricane Florence could arrive through the weekend, officials say.

North Carolina Governor Roy Cooper has urged residents to remain in shelters as the floodwaters from Storm Florence continue to rise across the state.

Active infections kill 4000 people a day worldwide, more than AIDS does. But the notion that a quarter of the global population harbors silent tuberculosis is “a fundamental misunderstanding.”

A novel study indicates promising avenues in an innovative approach for developing a vaccine against Plasmodium vivacious, the most prevalent human malaria parasite outside sub-Saharan Africa.

A WHO report estimates that more than a quarter of people worldwide – 1.4 billion – are not doing enough physical exercise, a figure that he barely improved since 2001.

The Democratic Republic of the Congo’s (DRC’s) 10th Ebola outbreak continued over the weekend, as officials reported three new deaths.

Technology

The government of Burkina Faso granted scientists permission to release genetically engineered mosquitos anytime this year or next,  researchers announced Wednesday. It’s a key step in the broader efforts to use bioengineering to eliminate malaria in the region.

Environmental Health

The impacts of climate change, from air pollution to extreme weather events, to disruptions to food and water systems will pose the greatest threats to global health in this century, and health leaders say it’s time for the sector to be a more active participant in the global climate debate.

Duke Energy said Thursday that three inactive coal ash basins in Goldsboro, North Carolina, are underwater after Hurricane Florence.  The electric utility said it’s monitoring the site and only a small amount of ash has leaked. But the heavy flooding has environmentalists worried about other sites and other hazards.

Climate change is the greatest health threat, and opportunity, of the 21st century and the health sector must lead the way to call on local, national and global policymakers to act now to significantly reduce climate pollution and build climate resilience,” said Dr. Maria Neira, the director of the Department of Public Health, Environment, and Social Determinants of Health of the World Health Organization, and the Public Health Institute is ready to meet the challenge head-on.

It’s no secret that California and the U.S. government are singing very different tunes when it comes to climate change.   The Golden State gathered a chorus of sorts at the Global Climate Action Summit, an international meeting of leaders and stakeholders in San Francisco Sept. 12-14.

Equity & Disparities

At the end of her mission to the country, Ikponwosa Ero, UN Independent Expert on the enjoyment of human rights by persons with albanism, issued a statement on Monday welcoming Kenya’s “unique achievements”, saying that the country was set to become a regional leader on the issue.

The philanthropist Bill Gates has thanked the UAE for its support in working to eliminate deadly diseases and reduce world poverty.

The HDI, compiled by the UN Development Program (UNDP), is used as a composite measure of global development, tracking national successes in health, income and education in 189 countries. Norway, Switzerland, Australia, Ireland and Germany top the rankings in the latest report, while Niger, the Central African Republic, South Sudan, Chad and Burundi have the lowest scores.

High poverty rates, low education and lack of insurance are all social determinants that are expected to lead to high mortality rates and negative health outcomes. Despite a 62 percent minority population with these characteristics in California, the state’s health profile was significantly better than the nation’s as a whole.

An estimated 5 million deaths per year in low and middle income countries (LMICs) are the result of poor quality care, with a further 3.6 million the result of insufficient access to care, according to the first study to quantify the burden of poor quality health systems worldwide.

In January, the United Nations Committee on the Rights of Persons with Disabilities will welcome Australia’s first female representative to the committee — Rosemary Kayess.

Women, Maternal, Neonatal & Children’s Health

Ending preventable maternal mortality and correcting unacceptable levels of disparity are essential to achieving Sustainable Development Goal (SDG) 3, which focuses on ensuring healthy lives for all.

Sexual and reproductive health and rights NGOs struggling to deliver services in the wake of the United States “global gag rule” have spent a year caught between donors, after the Swedish aid agency, a key funder of sexual and reproductive health and rights, said it could not support organizations that go along with the rule. This report builds on WHO’s long-standing work on young people’s health and rights, including the Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030), the Global Accelerated Action for the Health of Adolescents (AA-HA!) guidance, and contribution to the new UN Youth Strategy.  It was developed as part of the roadmap towards the development of a WHO strategy for engaging young people and young professionals.

More than 60 years after the drug thalidomide caused birth defects in thousands of children whose mothers took the drug while pregnant, scientists have solved a mystery that has lingered ever since the dangers of the drug first became apparent: how did the drug produce such severe fetal harm?

Public Health and Migration

by Eighmey Zeeck, posted in APHA IH Section, Conflict and Health, Disaster Response, Human Rights, Maternal and Child Health, Policy and Advocacy, Refugee and Migrant Health

Throughout history humans have been on the move, migrating due to famine, war, persecution, and to find a better life. In a new age of “zero tolerance” policies and deeming humans “illegal” it is important to understand that how global policy defines someone matters.

There are many terms for populations that are fleeing disasters and we have to understand globally accepted terms for populations on the move.

    1. Asylum-seekers are people “whose request for sanctuary has yet to be processed”. Every nation has their own asylum system to determine who qualifies for protection and how they request this protection. If the petition for protection does not meet the host country’s criteria the individual may be deported to their home country.
    2. Internally displaced people have not crossed any borders to seek safety but have moved to another location within their home country seeking safety or shelter.
    3. Refugees are people who are forced to flee their home country in order to seek safety from conflict or persecution. This group of people are protected under international law and are not to be sent back to the situation where their safety is at risk.
    4. Migrants are people who choose to move for work, education, family unification, etc. These people can go back to their home country and continue to be protected by their home country government.
    5. Undocumented migrant is a person who has entered a country without proper documentation, or their immigration status expired while in the host country and they have not renewed their status, or they were denied legal entry/immigration into their host country but have remained in the host country.
    6. Statelessness is someone who does not have a nationality. Individuals can be born stateless or become stateless due to nationality laws which discriminate against certain genders, ethnicities, or religions, or the emergence or dissolving of countries.

These international definitions are important, because it determines if, how, and when the international community can respond to crisis situations. A large caveat is that due to national sovereignty under international law a nation must request that international organizations like UNHCR provide international assistance to these particular communities. If nations do not request assistance or reject assistance then these populations are left without any sort of protection leaving them vulnerable and isolated, as seen with Syrian refugees in Lebanon. The international community has also seen the inhumane treatment of people seeking protection to include isolated detention on islands such as is currently used in Australia.

No matter how the international community defines these populations, they face poor health outcomes due to disease, economic stress, and trauma. Examples include:

  • An increase in child brides among Syrian and Rohingya refugee populations. This in turn affects infant and maternal mortality rates as well as the woman’s future economic prospects.
  • Malnutrition of both mother and child leading to increased death rates for children under five and stunting of growth in children that survive. This is currently being seen in Yemen.
  • Decreased breastfeeding rates due to maternal stress, disease, and separation from familial groups/support systems. An increase in breastmilk substitutes in refugee or displaced persons camps is also an issue that goes against international humanitarian policies.
  • During the Mediterranean refugee crisis the international community witnessed large groups of people risking their lives on overfilled boats that often sank, causing large scale loss of life. These refugees then faced xenophobia, closed borders, and detention upon their arrival.
  • Currently in the United States there has been an increase in detaining families and child migrants from Latin American countries for an indeterminate amount of time. Organizations like American Academy of Pediatrics have begun to discuss long term effects this type of detention has on child and adolescent health outcomes such as: high risk of psychological stress that may lead to anxiety and depression due to separation and forced detention, suicidal ideations, victims of assault by other children in these detention centers, or sexual assaults from other detainees or employees at these facilities.
  • In South America sovereign nations have closed their borders or placed restrictive regulations on Venezuelan migrants seeking food, shelter, and basic medical care for their families amid a massive economic crisis. Not only do these migrants face arduous journeys, but they also face poor health outcomes like malnutrition due to starvation, and the potential for contracting diseases due to poor sanitary conditions, and consuming non-potable water.
  • Migrants are a vulnerable population who can succumb to human trafficking and the modern slave trade along their migration routes. Migrants that are caught up in human trafficking often face abuse (mental and physical), serious injury from due to extreme work conditions, and exposure to communicable diseases from overcrowded and unsanitary living environments.   

Humans take immense risks to seek safety and new opportunities that they did not have in their home country. As an international public health community, whether we work in crisis situations or not, we must make it a priority to treat all humans in a humane manner. Health is a human right, and should be guaranteed for all.